Pushing photons

By David L. Weiss, MD

Dr. Weiss is the Physician Coordinator, Imaging Informatics at Carilion Clinic, Associate Professor of Radiology at the Virginia Tech Carilion School of Medicine, Roanoke, VA. He is also a member of the Applied Radiology Editorial Advisory Board.

The 1999 movie Pushing Tin explores the professional stress of two feuding air traffic controllers and its effect on their personal lives and relationships. The controllers labor daily in a dimly lit and featureless room, peering intently at multiple computer screens, while speaking constantly into a microphone. Every decision, even a seemingly trivial one, carries the potential for disaster. The public is only aware of their critical role and high-stakes contribution through the occasional negative publicity of an air traffic disaster.

I often feel that as a radiologist I work under conditions similar to these air traffic controllers. My physical environment is nearly identical. Likewise, the intense concentration needed during every reading session, where any mental lapse can lead to a fatal outcome, is emotionally and physically draining. One added element in radiology is the lack of timely feedback. A missed imaging diagnosis is often not immediately apparent and may only be discovered years later. Imagine leaving your job at air traffic control and being told that you will know in about 2 years whether 2 planes under your guidance have collided.

The air traffic industry is under intense government regulation and scrutiny. Shift length and working conditions are tightly defined and controlled. While we have similar regulations for our residents, I have always been puzzled by the lack of such oversight for attending radiologists and physicians in general. We all know when we are running on empty, but sometimes must continue to interpret cases without relief.

Like the physically isolated air traffic controllers, we rarely see our patients personally. In fact, many are often only dimly aware that we in fact are physicians. At a Radiological Society of North America (RSNA) annual meeting some years ago, I read in the Chicago Tribune of a Metro commuter who had collapsed. He was revived by several fellow passengers described as “a physician and 2 radiologists.”

In a dramatic exchange in the film, one of the controllers is a passenger on a plane being guided through, rather than around, a thunderstorm. Suspecting his rival at work on the ground of deliberately putting him in danger, he attempts to enter the cockpit.

Flight attendant: You can’t go in there. The pilot is flying the plane.

Controller: Oh, you really think the pilot is controlling this plane? That would really scare me.

Clinicians, like modern pilots, have become increasingly dependent on imaging for guidance. A patient seen in the emergency room with abdominal pain frequently receives a computed tomography (CT) scan. We as radiologists play a critical role in guiding the surgeon whether to send this patient home, to an observation bed, or immediately to surgery. Just as air traffic would come to a screeching halt with the failure of air traffic control, recall the system-wide chaos and frustration caused by your last major picture archive and communication system (PACS) or communication system downtime.

This dependency, while less recognized and certainly less acknowledged in the past, preceded PACS by many years. I recall an incident during my surgery rotation as a third-year medical student. Our chief resident received a phone call, and we all followed him to the ED to examine a patient with abdominal pain. After a brief history and physical, the resident announced he was admitting the patient with a diagnosis of sigmoid volvulus. How impressive. This man was a diagnostic genius. Several days later, I discovered the call had not been from the ED but rather from the radiologist, who had suggested the diagnosis based on the patient’s obstruction series.

As radiologists, we have tremendous responsibility to ensure not only our own diagnostic accuracy but also the safety of our technology. Recent nationwide campaigns to increase recognition among all physicians of radiation risk should have a salutary effect on patient health. Air traffic controllers have always had an acute awareness of their awesome burden to ensure customer safety.

At the end of Pushing Tin, the protagonists reconcile their differences. In the final scene, they climb the runway fence and stand in the wake of a landing 747 jumbo jet. They are tossed and buffeted through the air like small dolls—a deliberate reminder of the fearsome, sometimes destructive power of the technological marvels they guide through the sky.